The future of organ perfusion and re‐conditioning

Abstract

Summary Organ preservation and re‐conditioning using machine perfusion technologies continue to generate promising results in terms of viability assessment, organ utilization and improved initial graft function. Here, we summarize the latest findings and study the results of ex‐vivo/ex‐situ hypothermic (HMP) and normothermic machine perfusion (NMP) in the area of abdominal organ transplantation (kidney, liver, pancreas and intestine). We also consider the potential role of normothermic regional perfusion (NRP) to re‐condition donors after circulatory death organs before retrieval. The findings from clinical studies reported to date suggest that machine perfusion will offer real benefits when compared with conventional cold preservation. Several randomized trials are expected to report their findings within the next 2 years which may shed light on the relative merits of different perfusion methods and could indicate which perfusion parameters may be most useful to predict organ quality and viability. Further work is needed to identify composite endpoints that are relevant for transplanted organs that have undergone machine preservation. Multi‐centre trials to compare and analyse the combinations of NRP followed by HMP and/or NMP, either directly after organ retrieval using transportable devices or when back‐to‐base, are needed. The potential applications of machine preservation technology beyond the field of solid organ transplantation are also considered.

Surgical Techniques of Multiorgan Procurement from a Deceased Donor

“…Although most centers are reluctant to change their previous successful policies and it is a routine to perform double cannulation (aortic and portal) for dual perfusion of the liver, but nowadays with increased use of the pancreas and small bowel for transplantation, double perfusion may be replaced by the single aortic perfusion as a rule for most deceased donors [10]. With the advent of machine perfusion which used only one system for ex situ perfusion, there is increasingly more doubt about need for double perfusion and most studies shows that arterial perfusion is more important in saving the organ function especially the biliary system [17].…”

“…In contrast to static cold storage (SCD) which we discussed in all sections of this chapter, dynamic perfusion techniques use a perfusate for active perfusion of the organs in situ (en vivo) or ex situ (ex vivo) [35]. For example, normothermic regional perfusion (NRP) is an en vivo method for reconditioning organs for DCD by restoring oxygenated blood flow to the organs before procurement.…”

“…It may be used in a hypothermic (hypothermic machine perfusion or HMP) or normothermic (normothermic machine perfusion or NMP) milieu. For kidney grafts, it is shown that HMP reduced significantly delayed graft function both after DCD and donation after brain death in marginal donors [35]. NMP is an established method for confirming the functionality of marginal liver grafts by showing the function of the graft and preventing ischemic cholangiopathy and it is shown that this method reduced the discard rate by 50% [36].…”

Effects of Ischemia-Reperfusion on Tubular Cell Membrane Transporters and Consequences in Kidney Transplantation

“…Another ex situ organ preservation method, called Normothermic Machine Perfusion (NMP), is the subject of renewed interest. It intends to mimic physiological conditions in the human body and has shown promising results [108,109]. However, to the best of our knowledge, no metabolomic study has yet been conducted on perfusion fluid coming from NMP.…”

In Vitro/Ex Vivo Models for the Study of Ischemia Reperfusion Injury during Kidney Perfusion

“…As cold ischemia time remains one of the major risk factors for kidney dysfunction, NMP seems to be a major alternative [55], which it already represents for liver [56]. Moreover, an NMP circuit provides the necessary conduit for cell therapy application or pharmacological treatment prior to organ transplantation.…”